Fragile package - handle with care

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Violently shaking a baby can result in death or brain damage, but the problem is under-reported and often misdiagnosed, writes Natasha Wallace.

The baby is crying. All night. It is unrelenting, driving its parent to absolute despair. The infant is violently shaken, perhaps only briefly, but the accelerated, rotational force upon its head whips its brain like eggs, causing it to bleed and producing hundreds of retinal hemorrhages. As a result, the child is permanently brain-damaged, blind, or may even die within hours.

Even well-educated fathers - men are mainly responsible - confess to doctors that they simply "lost it".

Shaken baby syndrome, or non-accidental abusive head trauma, is an emotionally charged issue in which parents may be wrongly blamed or be unable to prove someone else hurt their child.

For parents in Australia there is scant information, no support groups and no national prevention programs. There is also a lack of awareness on the part of some health-care professionals.

Shaken baby syndrome is also widely under-reported and misdiagnosed, say doctors, partly because the early symptoms are similar to a viral infection or gastrointestinal upset - vomiting, diarrhoea, weepiness and lethargy. Survivors are likely to suffer intellectual impairment, cerebral palsy, epilepsy and cognitive/behavioural problems.

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In a court case last month, babysitter Marie Elaine Campbell, 64, was jailed for 4 years after she was found guilty of shaking an 18-month-old baby so violently that the infant almost died. Campbell was given a non-parole period of 18 months.

Maintaining her innocence throughout the trial, Campbell said she had fallen while holding Alexandra Whelan, who is now three years old and suffers permanent brain damage.

This was the first successful prosecution in NSW in which a child had not died.

The parents of another child claimed Campbell also inflicted abusive head trauma upon their five-month-old daughter, but were unable to prove their case. A doctor had diagnosed her with the flu, despite her intermittently going cross-eyed, but a few days later she was admitted to hospital in a critical condition.

The father of that child, who wished not to be named, says he and his wife were then subjected to "incredibly humiliating" scrutiny by police and the NSW Department of Community Services, until the case was dropped six months later.

The medical fraternity is divided on whether shaken baby syndrome can be proved, particularly by relying on the existence of subdural and retinal hemorrhages alone. The problem is compounded by the fact it is impossible to conduct medical trials, for obvious ethical reasons.

There are no national statistics on the number of cases, although the National Coroners Information System recorded two deaths of children under two due directly to being shaken in 2002.

In NSW there were 11 such deaths between January 1996 and June 2002, according to the NSW Child Death Review Team.

Doctor Kieran Moran, the director of forensic pediatrics at Sydney Children's Hospital, Randwick, estimates that about 30 babies present to NSW hospitals each year with shaken baby syndrome, a few of whom die.

It is generally inflicted upon babies up to six months old, with the peak age at two to four months, he says.

Moran usually can discern between an inflicted and an accidental injury but in a few cases each year he cannot.

Men are mostly responsible because they are unaccustomed to a crying infant, he says.

Research indicates fathers inflict the injuries in 45 per cent of cases, compared with the mother's boyfriend at 25 per cent and female babysitters and mothers at 15 per cent.

Doctor Otilie Tork, a pediatrician at the child protection unit at the Children's Hospital, Westmead, sees about 10 to 12 cases each year.

"I would say that there are other children who are presenting who don't get diagnosed - we're seeing the tip of the iceberg," she says.

"A lot of the parents who injure their children don't realise that what they're doing is going to hurt their child. They're crying so much, they're so frustrated, they lose control. Shaking actually calms a child because they've actually had brain damage - and it kind of reinforces that maybe it's less dangerous than slapping a child."

She points to a case where a "professional, very loving dad" confessed to losing his temper and shaking his six-month-old baby.

"He was absolutely mortified because he knew that it was wrong, but he was so stressed and he thought, 'I won't do it the next time'."

She hopes the issue will be addressed with a three-minute animated video, Shaking your Baby is Just Not the Deal, a collaborative effort between hospitals and counselling groups, due for release in September for Child Protection Week.

"We've done a survey of our video and found that some nursing and health professionals don't know that [shaking a baby] is dangerous - we fell off our chairs," she says.

An education program introduced in 1998 to all New York hospitals has resulted in a 50 per cent reduction in cases.

Aside from brain hemorrhages and swelling, and bruises to the child's soft-tissue areas such as the cheeks, doctors say the telltale sign is retinal hemorrhages, possibly hundreds, spread throughout the eye. It is estimated they are present in 80 per cent of cases.

Doctor Ian Kennedy, the head of ophthalmology at Sydney Children's Hospital, says there are "very few things" that cause this scattered pattern of retinal hemorrhages.

"If there is another cause, it is usually fairly obvious, like if the child has leukemia or a blood disorder - if a child falls down a three-storey building or gets hit by a car then the incidence of retinal hemorrhages is very low, less than 5 per cent," Kennedy says. "It appears to be a forwards and backwards shaking that produces the hemorrhages."

Also, while a GP can do a CT scan on a child's brain to check for subdural hemorrhages, Kennedy says only ophthalmologists are able to diagnose retinal hemorrhages using specialist equipment generally only available at major hospitals. This makes it extremely difficult for doctors to detect them. The pattern may also disappear after a few weeks.

But an article in the British Medical Journal in March revealed what it called "major shortcomings" in the literature on diagnosing shaken baby syndrome. It cited various studies that claim there is insufficient scientific evidence to support a diagnosis based on subdural and retinal hemorrhages alone, and points to a case in which a 14-month-old child, who died, presented with these symptoms after a television fell on his head.

"This is one of the debates - whether a short fall can cause retinal hemorrhages. The consensus of opinion [in Australia] is that it doesn't," says Kennedy. "I don't suppose that you can be 100 per cent certain. This is the problem."

Kennedy and Moran believe that shaken baby syndrome can be determined in the vast majority of cases because injuries from such things as car accidents result in a distinctly different pattern of retinal hemorrhages. In these cases they are usually centred around the optic nerve.

In the United States, where it is the leading cause of child abuse deaths with nearly 75 per cent of perpetrators being parents, and 60 per cent of those male, there is a plethora of information on shaken baby syndrome.

Baby Alexandra's mother, Kylie Whelan, who is a midwife, says she had never heard of the syndrome before her tragic ordeal. The worst part, she says, was being "pushed from pillar to post" by Sydney hospitals when seeking information, before she resorted to the internet.

"There's absolutely nothing in Australia, not a single thing," says Whelan. "There was no support group and there was no one we could turn to, even just a shoulder to cry on."

She says when she called the Children's Hospital at Westmead a year ago, she was told it had nothing available, and was encouraged to set up a support group.

Specialists agree that more research is needed, particularly on prevention and the long-term management of sufferers.

In the meantime, one message is clear: shaking is dangerous.

Says Kennedy: "Walk out or do something, put cotton buds in your ears - anything but shake the baby."

Parents needing help with a crying baby can call for advice on the following 24-hour numbers: